Case study: The use of a GP endorsed letter to increase the awareness of bowel screening amongst the South Asian community

A letter describing the importance of participating in bowel screening every two years as recommended by the National Health and Medical Research Guidelines was developed. The letter was ‘endorsed’ and mailed to eligible patients (aged 50-74 years) by one general practice by using their letterhead and signed by a doctor. An example of the letter is below in the Related Resources section. The practice was selected based on its patient population, which included a high proportion of people from South Asian backgrounds.

Between two and three months later, a sample of patients who were sent the letter were contacted by the practice to participate in a short interview to gain feedback about the letter and its impact (if any) on bowel screening behaviour. Questions focused on recall of the letter, understanding of its content, actions since receiving the letter and intentions to participate in bowel cancer screening.

The practice sent 2682 letters to patients aged between 50 and 74 years of age. The flow of participation in the evaluation interviews is outlined in the image below. In total, attempts to contact 113 patients were made, with up to three phone calls made per patient when no answer was initially received. Of the 97 patients that could be contacted, 46 agreed to participate in the evaluation interviews.

There were twice as many male participants as female participants. Seventy-two per cent of participants spoke a language other than English, predominantly Tamil and Sinhalese, suggesting that the target community was reached for this activity. Although the majority had completed a bowel kit in the past, only 23% had completed it within the last two years, as recommended in the National Health and Medical Research Guidelines.

Participants were asked about their recall of the GP letter, their understanding of the content, whether they had taken any action since receiving the letter, and whether they intended to complete their bowel screening kit when it next arrived in the mail.

Of those who interviewed, 40 remembered receiving the letter from their GP. Most felt that the letter was easy to understand and helped them to understand the importance of bowel cancer screening and to make a decision about whether or not to participate in bowel screening. Seventy-eight per cent of participants intended to complete the bowel kit when it next arrived. Others reported that they had already had colonoscopies and/or would follow-up directly with their GP.

When asked about further improvements that could be made to the letter, respondents were largely happy with its content and believed it to be a useful reminder for them to complete the bowel kit. Several suggested that it could be translated into their language (including Tamil, Arabic, Chinese and Macedonian). One suggested that more explicit information about why the Government monitors FOBT kit returns would be helpful.

The findings reported here are based on a very small, targeted sample of just 46 people. Although a target of 100 participants was set, this was not able to be achieved within the activity timeframe due to the limited availability of practice staff. The timing of the follow-up phone calls was also delayed due to the Christmas/holiday period. The responses cannot be generalised to the broader population, or the South Asian community, but do provide some initial insight that can be followed up in future work.

It was extremely challenging for practice staff to conduct the interviews, which they perceived to be time consuming in the context of their other work. Although funding was provided to allow dedicated time to conduct these, this time was not always available. Resourcing proved a significant barrier to achieving an adequate sample size. As a result, the interview process took longer than expected, with interviews taking place two months or more after the letters were sent, rather than within four weeks as planned.

The interviews were also conducted in English, which may have prevented some people from participating. Although people from culturally diverse backgrounds that were deliberately targeted in this activity, the findings may not accurately reflect the awareness and understanding of these communities, and should be followed up using more focused, culturally appropriate strategies.

The high level of recall of the GP endorsement letter is extremely promising, particularly given that interviews were conducted up to two months after the letters were sent, and after the Christmas/holiday period. This suggests that the letters were perceived as valuable, and that patients did engage with the content. This supports findings that more personalised reminders and endorsements from GPs and health professionals may be highly motivating for patients to participate in screening programs.

Overall, the GP endorsement letter appears to be useful to inform and remind patients about bowel cancer screening. It may be beneficial to send the letter in language to improve understanding and screening participation. However this is difficult, given that language spoken is not routinely captured at general practices, or by the National Bowel Cancer Screening Program, so it is difficult to identify who would require translated resources. Capturing this information is beyond the scope of this activity, but an important area for future attention.

It may also be important to better articulate the efficacy of completing the NBCSP kit instead of proceeding to colonoscopy (for low risk patients with no symptoms), as several patients cited this as their main reason not to participate, preferring to be guided for testing by their GP. Further medical history was not captured, so it is unknown whether there was reason for these patients to undergo colonoscopy and what their recommended follow-up pathway was. This trend has also been found in other activities examining GP attitudes to bowel cancer screening, with many continuing to recommend colonoscopy over screening. There remains work to be done to educate patients and GPs about the effectiveness of the FOBT kit to detect early stage cancer.

Nevertheless, this activity demonstrates that a simple, low cost initiative that can be undertaken at scale by general practices in Australia is perceived as useful by patients and may help to improve awareness, understanding and participation in bowel cancer screening.